Basic Information
| Provider Information | |||||||||
| NPI: | 1679759740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.S., CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 132ND PL SE UNIT E302 | ||||||||
| Address2: | |||||||||
| City: | NEWCASTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980599111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179954275 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2008 | ||||||||
| LastUpdateDate: | 12/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 102554 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.